Non-Delegated Provider Roster Submission

We have created a streamlined process for submitting provider updates. Approved entities are only required to submit one comprehensive roster to capture the following:

Enrollments – New providers being added to the existing contract
Demographic updates – Changes to provider information such as name, address, or specialty.
Terminations - Provider ending participation with the delegated group.

Please ensure that all provider changes (adds, updates, and terms) are reflected on your roster submission.

Provider Roster Submission Template (Excel | .xlsm)

Upload Roster *

Upload W-9(s):

Required ONLY if new TINs are being added that have never previously been enrolled under the delegated entity. If multiple W-9's must be submitted please combine all into a single .zip file to upload.

Upload Additional Documentation (OPTIONAL):

First Name: *

Last Name: *

Contact Email: *

Contact Phone Number: *

Tax ID Number *

Does your practice/facility have a website? * Yes No

Website URL: *

Confirm Website URL: * Please confirm the website address of the practice/facility

Attestation * I hereby certify the above information to be true and correct to the best of my knowledge.

In order to meet Federal and State contractual requirements to notify members of a provider termination, Meridian is requiring that providers submit a voluntary termination form at least 60 calendar days before the termination effective date.

Please attest to the following: * I understand that in order to provide 60-day prior notice to affected members my effective date of voluntary termination must be at least 60 calendar days from notification.

Last Updated: 09/29/2026